Circumcision and HIV: Harm Outweighs
"Benefit"
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Two
American-sponsored studies in Africa claim that adult male
circumcision significantly reduces the risk of acquiring HIV.(1)
Researchers then take the leap of recommending adult male
circumcision as an HIV prevention strategy. Publishing such a report
in the United States appears to support the American cultural
practice of circumcision. Such judgments are dangerous.
The
Kenya report spotlighted a 53% reduction of HIV acquisition in
circumcised men relative to genitally intact men. However, only 47
of the 1,391 (one in 30) genitally intact men in the study
contracted HIV, compared to 22 of the 1,393 (one in 63) circumcised
men. These figures showed that about 56 circumcisions were needed to
prevent one HIV infection, and 55 out of 56 circumcised men received
no benefit. In the Uganda study, investigators estimated that
67 circumcisions were needed to prevent one HIV infection while the
rate of moderate and severe circumcision complications was about 4%.
Therefore, the chance of such a complication was more than 2.5 times
greater than the chance of protection from an HIV infection, not
including complications that would appear years later. In addition,
an association between circumcision and HIV infection does not prove
a cause and effect relationship. There could be confounding
variables. For example, circumcision changes sexual behavior. The
studies failed to avoid selection bias and expectation bias. The
studies were stopped early, and duration of the trials were short.
No long-term followup can be done. The effects of commercial sex
workers, female circumcision, genital ulcers, unsafe medical
practices, nonsexual HIV infection, and condom use were not
included. Furthermore, the HIV status of the female partners in the
studies was not determined. We recommend using the common sense
test: if any other healthy body part (e.g., finger, toe, ear) were
recommended for removal to prevent an unlikely disease, would
American observers respond with equal approval?
The studies do not account for cultural
bias on the part of researchers.(2) The Cochrane Collaboration is an
international independent source of reliable evidence-based reviews
of healthcare information. It reports, "Circumcision practices are
largely culturally determined and as a result there are strong
beliefs and opinions surrounding its practice. It is important to
acknowledge that researchers’ personal biases and the dominant
circumcision practices of their respective countries may influence
their interpretation of findings.”(3) The lead researchers of the
African studies are known American circumcision
advocates.
Claims that circumcision
reduces the risk of acquiring HIV infection have been made for 20
years. Other studies have found no significant effect of
circumcision status on HIV acquisition.(4) Publication bias in favor
of positive results makes it more difficult to bring attention to
studies with negative outcomes. The fact is that the United States
has a high circumcision rate and the highest prevalence of HIV
infection in the developed world.(5) Other countries have lower
rates of HIV infection than the United States and do not practice
circumcision. National medical organizations unanimously find no
proven medical benefit for
circumcision and do not recommend it.(6) Furthermore, in a previous
study published on the effectiveness of condoms in preventing HIV
acquisition, heterosexual couples that included an HIV-infected
partner used condoms consistently in a total of about 15,000
instances of intercourse. None of the uninfected partners became
infected.(7) That’s why the American Medical Association states that
“behavioral factors are far more important risk factors for
acquisition of HIV and other sexually transmissible diseases than
circumcision status, and circumcision cannot be responsibly viewed
as ‘protecting’ against such infections.”(8) Using or promoting
unnecessary surgery when much less invasive, much less costly, and
much more effective methods are available (e.g., condoms) raises
ethical concerns. The cost of one circumcision in Africa can pay for
3500 condoms. The African study investigators also advise
circumcision for treating phimosis (nonretractable foreskin) when
other less invasive and less costly methods are available.(9)
Furthermore, the studies recommend the use of condoms in addition to
circumcision. Because of the superior effectiveness of condoms,
circumcision adds little additional protection.
Unlike Africa, America circumcises
males in infancy. The African adult studies cannot be applied to
American infants because of the difference between the two groups.
Because sexually transmitted diseases obviously cannot be
transmitted until an individual engages in sexual activity, a male
may make a decision to be circumcised when he is older without
losing this claimed “benefit.” If you were an adult male and had the
option of using a condom and getting virtually assured protection or
having part of your penis cut off to get a one in 56 chance of
protection, the choice is clear. Furthermore, by the time today’s
newborn boys become sexually active, HIV vaccine may be available.
American circumcision studies have found dozens of
“benefits,” from treating epilepsy and masturbation in the late
1800s to preventing sexually transmitted diseases today.(10) Though
such claims generally do not withstand scrutiny by medical policy
committees, their continued publication over the years has led to
medical myths while raising questions about some researchers’
motives. American researchers tend to avoid studying or
acknowledging the sexual and psychological harm associated with
circumcision.(11) This pro-circumcision bias in American medicine
reflects the pro-circumcision bias in American culture. The United
States is the only country in the world that circumcises most (56%)
of its male infants for non-religious reasons.(12) When Europeans
learn about this, they think we’re crazy.
Knowledge of
studies on circumcision harm is important to properly evaluating
advisability. There is strong evidence that circumcision is
overwhelmingly painful and traumatic.(13) Some infants do not cry
because they go into shock. Infants exhibit behavioral changes after
circumcision. Changes in pain response have been demonstrated at six
months of age, evidence of lasting neurological effects and a
symptom of post-traumatic stress disorder.(14) Anesthetics, if used,
do not eliminate circumcision pain.(15)
The common American
belief is that the foreskin has no value. That’s because most
American circumcised men (and doctors) do not know what they are
missing. Based on recent reports, circumcision removes up to
one-half of the erogenous tissue on the penile shaft, equivalent to
approximately twelve square inches on an adult.(16) Medical studies
have shown that the foreskin protects the head of the penis,
enhances sexual pleasure, and facilitates intercourse. Cutting off
the foreskin removes several kinds of specialized nerves and results
in thickening and progressive desensitization of the outer layer of
the tip of the penis, particularly in older men.(17) In a survey of
men who were circumcised after they became sexually active, there
was a reported decrease in sexual enjoyment after circumcision.(18)
One described it as like seeing in black and white compared to
seeing in color. If you have less, you feel less. Circumcision
removes the five most sensitive parts of the penis.(19) (For this
reason, many circumcised men are reluctant to use condoms because it
contributes to further decreased sensation. Reduced condom usage
adversely affects the HIV infection rate.) In a survey of those with
comparative sexual experience, women preferred the natural penis
over the circumcised penis by 6 to 1.(20)
Surveys of
circumcised men and clinical reports show that when men recognize
their loss due to circumcision and experience associated decreased
sexual sensitivity, they report wide-ranging psychological
consequences.(21) Most circumcised men seem satisfied because they
may not understand what circumcision is and the benefits of the
foreskin, they may not be aware of certain feelings and their
connection to circumcision, or they may be afraid of disclosing
these feelings.(22)
For American society, circumcision is a
solution in search of a problem, a social custom disguised as a
medical issue. Beware of culturally-biased studies on circumcision
posing as science, and take your whole baby
home.
(See About Bias and Circumcision Policy: A
Psychosocial Perspective.)
NOTES
1. Press
release from National Institutes of Health,
12/13/06.
2. Goldman, R., “Circumcision Policy: A
Psychosocial Perspective.” Paediatrics and Child Health 9
(2004): 630-633. 3. Siegfried, N., Muller, M.,
Volmink, J., Deeks, J., Egger, M., Low, N., Weiss, H., Walker, S.,
Williamson, P. "Male Circumcision for Prevention of Heterosexual
Acquisition of HIV in Men," (Cochrane Review) In: The Cochrane Library, Issue 3,
2003. Oxford: Update Software. 4. Carael, M., Van de Perre, P.,
Lepag, P., et al., “Human Immunodeficiency Virus Transmission Among
Heterosexual Couples in Central Africa,” AIDS 2 (1988): 201-205; Barongo,
L., Borgdorff M., Mosha, F., Nicoll, A., Grosskurth, H., et
al. “The Epidemiology of HIV-1 Infection in Urban Areas, Roadside
Settlements and Rural Villages in Mwanza Region, Tanzania,” AIDS 6
(1992):1521-1528; Chao, A., Bulterys, M., Musanganire, F., et al.
“Risk Factors Associated with Prevalent HIV-1 Infection Among
Pregnant Women in Rwanda,” National University of Rwanda-Johns
Hopkins University AIDS Research Team, International Journal of
Epidemiology 23 (1994):371-380; Grosskurth, H., Mosha, F., Todd, J.,
et al. “A Community Trial of the Impact of Improved Sexually
Transmitted Disease Treatment on the HIV Epidemic in Rural Tanzania:
2. Baseline Survey Results,” AIDS 9 (1995): 927-934; Changedia,
S., Gilada, I. “Role of Male Circumcision in HIV Transmission
Insignificant in Conjugal Relationship (abstract no. ThPeC7420),”
Presented at the Fourteenth International AIDS Conference,
Barcelona, Spain, July 7-12, 2002; Thomas, A., Bakhireva, L.,
Brodine, S., Shaffer, R. “Prevalence of Male Circumcision and Its
Association with HIV and Sexually Transmitted Infections in a U.S.
Navy Population,” abstract no. TuPeC4861, Presented at the XV
International AIDS Conference, Bangkok, Thailand, July 11-16, 2004.
5. Nicoll, A. “Routine Male Neonatal Circumcision and Risk of
Infection with HIV-1 and Other Sexually Transmitted Diseases,” Arch Dis Child 77 (1997):194-5.
6. Medical organization statements at
http://www.cirp.org/library/statements/. 7. De Vincenzi, I. “A
Longitudinal Study of Human Immunodeficiency Virus Transmission by
Heterosexual Partners,” New
England Journal of Medicine 331 (1994): 341-6. 8. Council
on Scientific Affairs, American Medical Association. Report 10:
Neonatal circumcision, Chicago: American Medical
Association, 2000. 9. Chu C, Chen K, Diau
G. "Topical Steroid Treatment of Phimosis in Boys," Journal of
Urology 162 (1999) : 861-3. 10. Gollaher, D. Circumcision: A History of the World’s
Most Controversial Surgery, New York: Basic Books,
2000. 11. Goldman, R., “Circumcision Policy: A Psychosocial
Perspective.” Paediatrics and Child
Health 9 (2004): 630-633; Boyle, G., Goldman, R., Svoboda,
J., Fernandez, E. “Male Circumcision: Pain, Trauma and Psychosexual
Sequelae,” Journal of Health
Psychology 7 (2002):329-343. 12. National Center for
Health Statistics, 6525 Belcrest Rd., Hyattville, MD 20782. Rate is
for 2003. 13. Ryan, C. & Finer, N. “Changing Attitudes and
Practices Regarding Local Analgesia for Newborn Circumcision,” Pediatrics 94 (1994): 232; Howard,
C., Howard, F., & Weitzman, M. “Acetaminophen Analgesis in
Neonatal Circumcision: The Effect on Pain,” Pediatrics 93 (1994): 645; Benini,
F. et al., “Topical Anesthesia During Circumcision in Newborn
Infants,” Journal of the American
Medical Association 270 (1993): 850-3; Gunnar, M. et
al., “Coping with Aversive Stimulation in the Neonatal Period:
Quiet Sleep and Plasma Cortisol Levels During Recovery from
Circumcision,” Child Development
56 (1985): 824-34; Williamson, P. & Williamson, M.,
“Physiologic Stress Reduction by a Local Anesthetic during Newborn
Circumcision,” Pediatrics 71
(1983): 40; Stang, H. et al., “Local Anesthesia for Neonatal
Circumcision,” Journal of the
American Medical Association 259 (1988): 1510; Lander, J.,
Brady-Fryer, B., Metcalfe, J., Nazarali, S., and Muttitt, S.
"Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical
Anesthesia for Neonatal Circumcision," Journal of the American Medical
Association 278 (1997): 2157-62; Romberg, R. Circumcision: The Painful Dilemma.
South Hadley, MA: Bergin & Garvey, 1985. 14. Taddio, A.,
Katz, J., Ilersich, A., and Koren, G. "Effect of Neonatal
Circumcision on Pain Response During Subsequent Routine
Vaccination," The Lancet 349
(1997): 599-603. 15. Lander, J., Brady-Fryer, B., Metcalfe, J.,
Nazarali, S., and Muttitt, S. "Comparison of Ring Block, Dorsal
Penile Nerve Block, and Topical Anesthesia for Neonatal
Circumcision," Journal of the
American Medical Association 278 (1997): 2157-62. 16.
Taylor, J., Lockwood, A., & Taylor, A., “The Prepuce:
Specialized Mucosa of the Penis and Its Loss to Circumcision,” British Journal of Urology 77
(1996): 294. 17. Taylor, J., Lockwood, A., and Taylor, A. "The
Prepuce: Specialized Mucosa of the Penis and Its Loss to
Circumcision." British Journal of
Urology 77 (1996): 291-95; Ritter, T., and Denniston, G.
Say No to Circumcision.
Aptos, CA: Hourglass, 1996; Money, J., and Davison, J. "Adult Penile
Circumcision: Its Erotosexual and Cosmetic Sequelae," Journal of Sex Research 19 (1983):
289-92; Cold, C., and Taylor, J. "The Prepuce." BJU International 83 (suppl. 1)
(1999): 34-44; O'Hara, K., and O'Hara, J. "The Effect of Male
Circumcision on the Sexual Enjoyment of the Female Partner," BJU International 83 (suppl. 1)
(1999): 79-84; Hammond, T. "A Preliminary Poll of Men Circumcised in
Infancy or Childhood," BJU
International 83 (suppl. 1) (1999): 85-92; Rhinehart, J.
"Neonatal Circumcision Reconsidered," Transactional Analysis Journal 29
(1999): 215-21; Goldman, R. Circumcision: The Hidden Trauma.
Boston: Vanguard Publications, 1997. 18. Kim, D. & Pang, M.
“The Effect of Male Circumcision on Sexuality,” BJU International (2007): in
press. 19. Sorrells, M. et al. "Fine-Touch Pressure Thresholds in
the Adult Penis," BJU International 99 (2007): 864-869. 20.
O'Hara, K., and O'Hara, J. "The Effect of Male Circumcision on the
Sexual Enjoyment of the Female Partner," BJU International 83 (suppl. 1)
(1999): 79-84. 21. Hammond, T. "A Preliminary Poll of Men
Circumcised in Infancy or Childhood," BJU International 83 (suppl. 1)
(1999): 85-92; Rhinehart, J. "Neonatal Circumcision Reconsidered,"
Transactional Analysis
Journal 29 (1999): 215-221. 22. Goldman, R. Circumcision: The Hidden Trauma.
Boston: Vanguard Publications,
1997.
© Circumcision Resource
Center
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